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Insured Information
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Home Address*  
  
City*  
State/Province*  
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if Non US/Canada
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if Non US/Canada
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Beneficiary Information
Beneficiary*  
Relationship*  
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Contingent Relationship  
 
Policy Information
Purpose of Insurance*  
Air Travel  
Will all air travel be on regularly scheduled airlines?
Yes No
  
Desired Benefit Level*  
Not to exceed 10 times annual salary; In US Dollars
Coverage Requested   All-Risk, 24 Hour Common Carrier Air Travel Only
Optional Coverage   War, Acts of War or Terrorism
Benefits Requested   Accidental Death (AD)
Accidental Death and Dismemberment (AD+D)
Policy Effective Date*  
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Final Day of Coverage Date*  
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Travel Itinerary
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Health Questions
Provide Details for Any 'Yes' Answers Below

Yes No   Have you any physical defect or infirmity?
Yes No   Is your sight or hearing defective?
Yes No   Have you ever suffered from any nervous or mental condition, fainting episode, blackout, fit, or paralysis of any kind?
Yes No   Have you ever suffered from high blood pressure, a heart condition, rheumatic fever, or diabetes?
Yes No   Have you ever suffered from a "slipped disk" or other spinal disorder, a hernia, or any rheumatic or arthritic condition?
Yes No   Have you ever been declined or accepted on special terms for life, accident, or illness insurance?
Yes No   Do you intend to engage in hazardous sports or any other pastimes that expose you to extra personal injury?

Provide details for any question answered "Yes" in the space above
 

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(source id: wtc)

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